As states press forward to implement the newly required work reporting requirements (WRRs) for Medicaid expansion adults starting next year, researchers at Georgetown CCF remain concerned about coverage losses among those adults who do everything right but still fall through the cracks and become disenrolled. Leo Cuello, Joan Alker and others at CCF have detailed the experiences of states who have tried (and failed) at implementing Medicaid work requirements, where the red tape for both the exemptions and work reporting itself caused many eligible adults to incorrectly become uninsured. To that end, every required exception to the new WRRs in H.R. 1, also known as the One Big Beautiful Bill Act (OBBBA), raise unique questions about how states will ensure exempt adults are quickly and successfully identified and taken off the list of required WRR enrollees.
Pregnant and postpartum women are among those who are exempted from WRRs under the new law. How they navigate through the exemption process in each state remains the major unanswered question. And like many Medicaid topics, the answers aren’t simple. Our colleagues at the Urban Institute dug into the risk posed by H.R. 1’s new requirements for pregnant and postpartum women in a new report, Ensuring Continuous Coverage for Pregnant and Postpartum Medicaid Enrollees Under OBBBA, to help inform states on ways to protect their coverage during an already-vulnerable time of change to a growing family.
Most of the Medicaid provisions of H.R. 1 – semi-annual eligibility redeterminations and WRRs, among others—target or only apply to Medicaid expansion adults. Some Say Ahhh! Health Policy Blog readers may be surprised to learn that pregnant women may be enrolled in one of a number of Medicaid categories, including Medicaid expansion. Expansion, along with the postpartum extension from 60 days to 12 months postpartum, gave many more low-income women of child-bearing age in expansion states the chance to have consistent coverage before, during and after pregnancy. Urban Institute researchers looked at Medicaid enrollment data from 2022, finding that during the month of delivery more than one-third of pregnant women in Medicaid expansion states were enrolled in the pregnancy category, with roughly the same percentage enrolled as ‘1931’ low-income parents, detailed in Figure 1 below from page 8 of the new report.
It stands to reason (but should be confirmed in each state!) that pregnant or postpartum women enrolled in other categories will be taken off the table automatically for WRRs. But the report also found that 15.6 % of perinatal women – more than 137,000 across the 36 expansion states reviewed –were enrolled the Medicaid expansion category during the month of delivery, and even more six months prior. These rates vary considerably by state, with Montana (43%) and Louisiana (40%) showing the highest rates of pregnant women enrolled in expansion. But, importantly, the numbers here matter, too. The paper details the number of perinatal women enrolled in the expansion category in 2022, where available, ranging from just over 100 in Rhode Island and Utah to more than 20,000 pregnant enrollees in California.
Why does this matter?? States can’t exempt pregnant women from WRRs or more frequent eligibility checks unless they know they are pregnant or postpartum. States are not required to track pregnancy in the expansion category, so finding a simple way to find and exempt pregnant women is easier said than done. But it’s important to make happen, since the study also found that more than half of the pregnant or postpartum women enrolled in expansion had chronic physical or mental health conditions.
The report details ideas raised by stakeholder interviews, such as using claims data to flag pregnancies for exemption and allowing self-attestation to protect enrollees as long as they are pregnant and during the 12 month (in most states) postpartum period. It lays out recommendations for states along these lines, such as improving timeliness of claims data reporting to automate exemptions, relying on ex parte renewals, ensuring enrollees can self-attest to pregnancy or postpartum status, and/or moving them from the expansion to the pregnancy coverage category. Dedicated outreach, education and simplified materials on the complex maze of new requirements will also be critical for enrollees and the providers and systems that serve them. Authors add actions CMS and other stakeholders can take to protect pregnant and postpartum women.
The clock is ticking. Is it too late for maternal and child health leaders to have a meaningful impact on the state WRR exemptions process? The rapid implementation timeline for H.R. 1 meant that already-strapped state agencies were in many ways behind before the ink on the new law was dry. But that shouldn’t keep states from considering the unique circumstances of enrollees who should be protected. For this reason, the report raises the importance of monitoring H.R. 1’s impact on pregnant and postpartum women. Maternal health advocates, providers, state policymakers and others should call for transparent data and use enrollee experiences to inform the implementation process to offer improvements over time. No pregnant or postpartum woman should become uninsured due to unnecessary red tape.
